Provider Demographics
NPI:1639520273
Name:JOHNSON, ALICE VICTORIA (CPNP)
Entity Type:Individual
Prefix:MISS
First Name:ALICE
Middle Name:VICTORIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 E 88TH ST
Mailing Address - Street 2:APT 2D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-4904
Mailing Address - Country:US
Mailing Address - Phone:248-470-2065
Mailing Address - Fax:
Practice Address - Street 1:355 E 88TH ST
Practice Address - Street 2:APT 2D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-4904
Practice Address - Country:US
Practice Address - Phone:248-470-2065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-24
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382724363LP0200X
NY700935163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse